Understanding Barriers to Healthy Behaviors in College Black Men in College Black men

Abstract

Objective

Due to the short life expectancy of Black men, it is important to understand what impacts health behaviors in this group so that interventions and programs can be developed to improve their health behaviors which may help increase the life expectancy of Black men. The purpose of this study was to understand what perceived barriers exist for Black college men that prevent them from engaging in healthy behaviors.

Participants and Methods

Thirty-five Black male students at a southern Historically Black College and University (HBCU) participated in five focus groups and four interviews. Qualitative analysis was used to analyze data for similar themes and codes.

Results

Perceived barriers to engaging in healthy behaviors appear to be influenced by image, food cost, and education. Cues to action for not engaging in healthy behaviors appear to be related to role models.

Conclusions

Black college men are not adequately informed or educated about elements that can impact their health and how they can improve it. College administrators and researchers should develop interventions that include elements of increasing health knowledge and age appropriate role models to improve health behavior change among this group.

Black males have the shortest life expectancy and the highest rate of premature mortality of any race by gender group in the US.^1-2 Yet, there is a lack of research that specifically focuses on the health and the health behaviors of Black males in college. Research that does include Black male college students is mainly focused around the sexual health behaviors of condom use and sexually transmitted disease testing and knowledge.^3-5 However, two of the top five main causes of death in Black males 15 to 24 years of age are heart disease and cancer.⁶

Research confirms that different risk behaviors at different ages increased the risk of death in Black men.⁷ Because risk behaviors varied by age group, researchers recommended that health promotion strategies and interventions be developed and tailored for different age groups.⁷ For this reason, research needs to look at what influences health behaviors in Black men of all age groups, particularly young Black men. Because many risk factors for chronic conditions are preventable, it is important to understand what influences young Black men to engage in behaviors that might put them at greater risk to develop conditions such as obesity and heart disease later in life.

Given their poor health profile, across their adult life, Black men on college campuses are an important population to focus on. College-aged populations have some of the highest rates of binge drinking, HIV infection, and obesity.^8-10 Specifically, Black men aged 20-24 and 25-29 have gonorrhea rates 10.7 and 8.9 times the rate among white males in the same age groups, respectively.¹¹ Additionally, Black men have one of the highest rates of obesity.¹² One study using a mainly Black college sample has reported Black college men having a higher prevalence of Metabolic Syndrome.¹³ Some of the main negative health behaviors cited among Black college students are unsafe sex, alcohol use, and lack of physical activity.¹¹

Because Black men with greater education have been found to have poor health outcomes such as obesity and stress, it is important to understand what barriers prevent this group from engaging in healthy behaviors as a way to develop interventions to reduce and eliminate negative health outcomes among this group.^14-16 Improving healthy behaviors in this group may help reduce their risk for chronic conditions such as obesity and heart disease which could help reduce health disparities that exist within this group.

Masculinity is one element that has been reported to impact health behaviors and outcomes in men.^17-18 Masculinity can be defined as the goals, beliefs, or values one associates with being a man.¹⁹ For Black men on college campuses, masculinity has been shown to impact their behavior and interaction with others on campus.^20-23 It has been recommended that a way to improve health behaviors in Black men is by understanding the role masculinity plays in the health behaviors Black men display across the life course.^7,9 The potential for masculinity to impact health behaviors was reported in research on health campaigns.¹⁷ This research reported that health campaigns using masculinity to change negative behavior to positive behavior may actually cause men to engage more in the negative or risky behavior.¹⁷

Recommendations for improving college men’s health include using peer counselors and training male and female students so they can assist their friends with health decisions and provide encouragement.²⁴ The idea of peer involvement or support is echoed in research on Black college men reporting that having space to interact with peers on campus is important because it allows them to interact with other Black men to talk about their experiences and seek or share advice with one another on different topics.²⁵ Although studies have investigated health among Black college men, few studies have focused on what influences the health behaviors they engage in. Thus, this study seeks to add to the literature by investigating what barriers prevent Black college men from engaging in healthy behaviors. By understanding what barriers exist for engaging in healthy behaviors among this group, colleges can develop more targeted programming to address these barriers and improve overall health. Additionally, research has reported differences in the type of stress and masculinity among Black males at HBCUs and PWI; therefore, this study seeks to add to the literature by studying health behavior influences in Black men at a HBCU.^21,26 The following research question guided this study: What perceived barriers impact health behaviors in Black college men?

Methods

This study employed a qualitative design with the use of focus groups and in-depth interviews comprised of black male students from a HBCU in the southern United States. Inclusion criteria for participation in the study were: currently enrolled in the university where the study was conducted, self-identify as African American or Black, and male. Because the male population at this HBCU is much smaller than the female population, participants were recruited using their campus email. After receiving IRB approval, a list of emails (without student names) for all Black male students enrolled during the fall 2015 term were obtained.

All Black male students received an email informing them that a study looking at health behaviors in Black males needed participants. In this email, participants followed a link that allowed them to select three possible focus group dates. This email was sent out three times a week starting in October 2015 through November 2015. Participants were then emailed letting them know which date they were selected for. Participants were also sent reminders for their focus group day the day before and the day of their focus group. To obtain additional participants, two focus groups were held in January and February 2016 with participants recruited through a convenience sample.

Procedure

Focus groups where conducted by the second author. The focus groups lasted no more than 1.5 hours. Because initial recruitment involved participants selecting potential focus group dates, some focus groups didn’t have enough participants show up; thus, some focus groups became in-depth interviews. Having a mix of both methods allowed for assessment of group dynamics with the responses while comparing if responses were based on group dynamics with the in-depth interviews. Focus group questions were guided by the Health Belief Model (HBM) and previous work by the first author related to masculinity in Black men. The HBM was used because it suggests the likelihood of one engaging in a behavior based on perceived susceptibility, perceived severity, perceived barrier and benefits, and cues to action.²⁷ For the purposes of this paper, responses related to the HBM construct of perceived barriers were reported. Focus group and interview questions are listed in Table 1.

Table 1.

Focus Group and Interview Questions

How do you believe being a man impacts your health? How do you believe being a Black man impacts your health? What health behaviors (good and bad) do you engage in? Why do you engage in these behaviors? How does being a man determine if you engage in these behaviors? How does being a Black man determine if you engage in these behaviors?

Before all focus groups and interviews, informed consent was explained and received. Additionally, all participants completed a brief demographic questionnaire. All focus groups and interviews were recorded and transcribed by the first author and a research assistant. After all focus groups and interviews were conducted, each participant received a $50 Wal-Mart gift card. They were unaware of the amount of the gift card or that they all would receive a gift card prior to their participation.

Data Analysis

Thematic analysis was conducted by the first author and five research assistants. Because qualitative analysis software was not easily available for the student research assistants, the first author picked an analysis method that was easy to explain and easy for the research assistants to analyze the data they were given. All analysis was conducted by hand using a process of chunking and coding text for themes and sub-themes based on methods used by Griffith and colleagues.^28-33 In the first step, each research assistant was given a transcript of a focus group or interview and asked to pull out chunks of data that related to a participant’s reference about health behaviors they engaged in and data related to a participant’s reference on their thoughts about their health. The chunks of data had to stand on their own without the full transcript and had to explain either a health behavior or a health thought. Additionally, information such as focus group or interview number and transcript page number were also included. For the second step, data from step one was checked by having another research assistant look over the document to make sure no additional data chunks were missed. The third step involved having one research assistant combine all data chunks from steps 1 and 2 into two documents, one for health behaviors and one for health thoughts. For the final step, all research assistants were given the two documents with data chunks for health behaviors and health thoughts and asked to list elements that were similar across all data. After this step, the first author reviewed all documents to look for similar themes.

Results

There were a total of 35 participants, who included five focus groups and four interviews. The number of focus group participants consisted of one group of four, three groups of six, and one group of eight. Additionally, one interview included two participants. Most participants ranged in age from 18 to 25 years old with one participant being 34 years old. Participants represented all undergraduate and graduate levels at the university used in this study. Because undergraduate and graduate participants were mixed within each focus group, it would have been difficult to delineate the qualitative responses of undergraduate and graduate students. Therefore, undergraduate and graduate students were used for this research. While there may be some difference between undergraduate and graduate students, understanding perceived barriers to healthy behaviors are important for both groups.

Masculinity

Masculinity’s impact on behaviors in Black college men has been noted throughout the literature.^20-23 Therefore, understanding the impact Black college men believe masculinity has on their health behaviors is important. After participants were asked about the behaviors they engaged in, they were asked how being a man and a Black man determined if they engaged in these behaviors. Most participants talked about the societal expectations of how men are supposed to behave as it relates to health and how that sometimes impacts what behaviors they do or do not engage in.

I would say like with the whole healthy eating thing. Like that’s been something I just started this year, but in the past it’s always been like. Oh I’m a man, I don’t need to cook, especially since we’re all young. It’s like oh and I’m a young man at that. I don’t need to know how to cook or I shouldn’t be cooking. I can eat fast food right now, it’s fine.

… men we think that we’re invincible so whatever we put into our body or whatever we do with our body, we feel that ‘man nothing ain’t gone happen to me. I’mma survive this. I’mma do whatever. I’mma do whatever; I’m still gone make it’. So we don’t worry about what we put into our bodies or what we do with our bodies. We just put it in and just keep it going. All we just trying to do is just make it pass today. Make it to tomorrow.

When asked how being a Black man impacted them engaging in these behaviors, many stated that Black men were expected to do more which translated into them engaging in certain behaviors at a higher level.

…back to what he was talking about when he was saying that a black man’s resume has to be better than … uh white man. I think that’s how we feel like internally about everything almost. Everything and that goes along with like exercising the most, drinking the most, eating the most, just being down, just being strong. What we think is strong I mean.

With all participants it appeared that societal expectations of them as men and Black men factored into the health behaviors that they engaged in. This is important to note because it provides some context to the factors they listed as barriers to them engaging in healthy behaviors.

Barriers to Health

Participant responses on health beliefs and health thoughts were separated into two constructs from the HBM, perceived barriers and cues to action. Overall, there were a lot of barriers to healthy behaviors with few cues to action around engaging in healthy behaviors.

Perceived Barriers

Participants mentioned three main barriers to them having the health they would like or engaging in the healthy behaviors they would like. While these areas report hindrances to their health, these are also areas that if improved could be cues to action for them engaging in healthy behaviors.

Image

As it relates to their image, participants expressed feeling like there was an expectation that they were already healthy or they were supposed to engage in certain unhealthy behaviors. Thus, many felt like being a man determined the type of behaviors they engaged in and living up to a certain male image was why they engaged in certain behaviors. Participants expressed the feeling that as a man you have to be stronger or better than everyone else. As stated by one focus group participant,

Society kinda tells us like how we need to be strong, not worried about something. We don’t really focus on our health and if something’s wrong…we just kinda think like oh we need to get over it or it will pass.

They also felt that as a man you have to lead in everything that you do, good or bad behavior, because no one can be above you, “Like as a man you just have to be the leader, you just have to take that prime position on any health behavior you make.” They also believed that being a man, particularly a Black man, came with expectations.

…as a black man you’re kinda, within the community, you know you’re kinda expected to be engaged in those [unhealthy behaviors]…

Perceiving that they have these type of expectations placed on them could make it hard for them to engage in healthy behaviors when the expectation is that they should engage in unhealthy behaviors. Additionally, if they believe that they should be the best in all that they do, they might engage in an unhealthy behavior fully (i.e. binge drinking) so that they are seen as leaders.

Cost

Cost was an additional barrier to healthy behaviors. Specifically, participants mentioned the cost associated with engaging in healthy behaviors. They also talked about having no control over the healthy behaviors they didn’t engage in due to the cost of healthy items and their lack of financial resources.

…the close proximity of fast food restaurants really hinder us from eating healthy…So I feel like a lot of the, the um urban communities like that they’re suffering because they can’t afford to buy the healthy foods and there’s no healthy foods around them.

…my mom buys the groceries…I’ve tried to suggest aye instead of buying that, why don’t we buy this. And it’s like you gone pay for it alright you right, I’m gone shut up. I just can’t tell her what to do, so.

They also felt that their lack of financial resources restricted their ability to be able to buy healthy food even if they wanted to eat healthy food.

…I would argue that my pockets uh depict my health behavior. So, you know, if I’m kinda broke and I’m, and I’m hungry gonna hit up that McDonalds. You know, if I have, have grocery money I’m probably gonna go to the grocery store see what that’s talking about. If I have extra money, you know, maybe get a gym membership

Education

Education was another barrier to engaging in healthy behaviors. Specifically, when asked about why they engage in good or bad behavior, many participants stated that they did not have someone explain to them what is healthy and unhealthy; therefore, they weren’t knowledgeable on how to engage in healthy behaviors and which behaviors to stay away from. Even though some may have had a mother who made sure they engaged in healthy eating, they still didn’t have someone explain to them what specific things they should do to be healthy.

But in regards to like the Black male, I’ll say he’s even more so confused because he doesn’t even have access to like some of that knowledge where it’s like, you know, ok well eat this instead of that. And just understanding the basics of like how to even lose weight or gain weight or what are healthy foods especially in a society where they tell you, you know, you’re meat and potatoes…

Uh we, we receive kinda less I guess people don’t really tell us that we need to work out because usually you know black males are naturally fit or naturally strong… It’s not that much important to everybody else to tell us that we need to be healthy. So it’s kinda like either you know about it or you know that you have to be healthy or it’s, it’s pretty much too late like you’ve already contracted some type of chronic disease or something like that and then we worry about being healthy.

…speaking as a young black man who didn’t necessarily have another male, older black male like influential and active in my life. I don’t necessarily know what comes along with men’s health and like what to check for and like what I could be susceptible to and like how to take care of myself as I have to learn through trial and error.

Cues to Action

Participants mentioned one element that served as a cue to action that encourages them to engage in unhealthy behaviors or to engage in healthy behaviors. Because these cues to action could be around healthy or unhealthy behaviors, they are areas that should be improved to increase the likelihood of college Black men engaging in healthy behaviors.

Role Models

The element that served as a cue to action was role models. Role models were divided into three categories: peers, family, and outside influence. Participants agreed that the behaviors they engage in are sometimes determined by those around them such as their peers. They stated they may not plan on engaging in a behavior, but if their friends mention it, they might be more likely to engage in the behavior. As stated by one interviewee, “You feel that if your friends are doing it you want to do it too”.

Family was also influential on the behaviors they chose to engage in, good or bad. Additionally, participants talked about how not having a role model their age engaging in healthy behaviors was a hindrance for them engaging in healthy behaviors.

…I don’t know what I’m supposed to be doing at the age of 19. Like we don’t have that, like it’s so concentrated. Like we only have the older generations view on like men growing up.

They expressed wanting to engage in healthy behaviors but without having a role model their age to look up to, it was hard to do the things that everyone tells them they should be doing (e.g. safe sex, drinking water, exercising).

It’s hard to find a positive 19 year old black male who’s healthy, getting the good grades, and like supreme health. It’s like you gotta pick and choose what you wanna do. Do I wanna get good grades and have bad health behavior or do I wanna you know kinda focus on this area. It’s hard to just be the 100 percent superman health behavior somewhere you gonna mess up and you just gotta pick and choose where you wanna do it and those consequences associated with it.

Comment

This study examined barriers to healthy behaviors for Black college men. This study also examined what elements may prompt Black college men to engage in healthy behaviors. Research on Black men and health behaviors has mainly focused on what health behaviors they engage in, their beliefs, and how these behaviors impact their overall health outcomes, not the factors that impact their engagement in these health behaviors.^3,7,34-36 Because health behaviors are influenced by many factors, it is important to understand what elements outside of the individual’s knowledge and beliefs impact the behavior they engage in. It is recognized that findings from this study may not be applicable to all Black men, but it is believed that these findings further Black men’s health research by researching what impacts health behaviors in younger groups of Black men.

Findings from this study support previous research reporting that elements such as masculinity and lack of awareness were barriers to Black men engaging in health-seeking behaviors.³⁷ Research has also reported that certain displays of masculinity impact health outcomes in men.^17-18 Conversely, health campaigns using masculinity to encourage certain health behaviors, such as sexually transmitted disease testing, were found that they may actually cause men to engage more in the behavior, e.g. having sex with more partners.¹⁷ Findings from this study support the notion that societal expectations of men and Black men impact whether Black college men engage in healthy behaviors. For example, the perception that men have to be leaders and strong in everything, determined how far participants would go with a behavior such as heavy or binge drinking. Because these prior studies included participants from a wide range of ages; it can be assumed that masculinity does impact the healthy behaviors Black men of all ages choose to engage in.³⁷

This study also reported that perceived barriers to engaging in healthy behaviors for Black college men included image, education, and cost. These findings are similar to other research reporting that economics and knowledge impact health behaviors among Black college men.^38-39 Additionally, it has been reported that limited access to healthy food was a barrier to physical activity and healthy eating among college men.⁴⁰ Research has also reported that some barriers to healthy eating in young adult males and weight management in males and females were unhealthy food being more accessible and cheaper and the social influence of those around them.^38,41 Another study reported one barrier to fruit and vegetable consumption in urban, immigrant Black men was their cost and someone else having to prepare the vegetables.³⁹ Additionally, it was also reported that a higher knowledge about the recommendations for the number of servings of fruits and vegetables was associated with higher fruit and vegetable consumption.³⁹ Findings from this study also support the notion that if Black men had more knowledge about the types of food they should eat, they would eat more of those food items.

In addition to perceived barriers to engaging in healthy behaviors, this study also reported that Black college men don’t believe they have many cues to action for them to engage in healthy behaviors. Similar to other research, findings from this study report that friends have an influence on the type of behavior college Black men engage in.⁴² Research has reported that fatalism, belief that you will die at a young age, of one’s friends had a positive effect on risky behaviors adolescents engaged in.⁴² Findings from this study also reported that college Black males want role models their age who are engaged in healthy behaviors so that they can emulate them. This finding supports a larger concept that peer support, assistance given by non-professionals that includes emotional, social, and practical assistance to encourage healthy behaviors, may be a more effective way to engage hardly reached groups, based on individual, demographic, or cultural-environmental factors, and improve their health outcomes.⁴³

Limitations

This study took place at a small HBCU which may have accounted for the low participant numbers. However, the response rate for this study was a little over 7% which was almost half the university’s total Black male enrollment (16.5%) for fall 2015.⁴⁴ Because the participant numbers were low, findings may not be representative of all Black males at the university or generalizable to a larger group of college Black men. Since this study was conducted at a HBCU, the results may be different for Black men at a PWI. Because campus dynamics are different at a PWI and a HBCU, findings may be different for Black men attending a PWI.

Also, recruiting participant through campus email may have accounted for the low number of participants. In efforts to make sure that all Black males at the campus were aware of the study and had an equal opportunity to participate, student emails were used as the main way to recruit participants. Because students may not check their emails regularly, persons who may have participated in the study were not aware of the study because the information was sent via email. Additionally, sending the email twice a week may have caused the email to be overlooked as junk mail by potential participants because it was sent out frequently

Conclusions

Black men continue to suffer disproportionately from many health conditions such as heart disease and diabetes. Because Black men suffer from these conditions at a higher rate and at a younger age, understanding what influences health behaviors in Black men at all ages may be a way to decrease adverse health outcomes within this population which may increase their overall life expectancy and reduce the health disparity burden within this group. While Black men with education are more likely to have poor health, understanding the barriers to engaging in healthy behaviors in Black college men may be vital to reducing adverse health outcomes in middle–aged and older Black men.^14-16 Understanding barriers to healthy behavior can be beneficial in developing programs around improving healthy behaviors in Black college men. Additionally, this knowledge may also be beneficial in making sure that messaging or programming to improve healthy behaviors for Black college men be tailored around culture, age, and gender.

This study provides insight into the perceived barriers and cues to action for healthy behaviors in Black college men. Findings from this study have implications for college health promotion and wellness programs. College health professionals can use findings from this study to develop groups on campus for Black male students that serve as a forum to provide knowledge on different health issues and concerns while serving as a space for Black males on their campus to meet other Black males who may be examples of how to engage in different healthy behaviors. Additionally, college health professionals should work to train Black male and female students as peer educators who can provide health information to other college students through forums, newsletters, and events. Because social groups have an influence on healthy behaviors, training Black college students as peer educators could be a way to influence the health behaviors of Black college men.

Future research in this area should examine what type of role model Black college men believe would cause them to engage in healthier behaviors. Additionally, research should examine the role Black college females believe they play in Black men’s health. Because this study was conducted at a HBCU, future research should examine if these concepts are true for Black college men at PWIs.